Introduction: Quality improvement projects have begun to standardize surgical work flow as a component to optimize operative room (OR) efficiency. Removing special cause variability resulting from non-surgical waste is an obvious target; however, surgical resident education must be maintained even in the setting of process improvement. There are no published data describing the impact on operative time of resident identified risky or uncomfortable procedural steps during posterior instrumented fusion (PIF). Self-identification of risk or discomfort in surgical steps may allow for shorter OR time and reduced cost, without sacrificing resident education.

Methods: PIF procedure steps were defined. An 8 two-part question survey regarding surgeon comfort level and perceived risk assessment at each step was developed, and completed by junior (17) and senior residents (10), and faculty (6) from orthopedic and neurological surgeons. A risk matrix was constructed defining two zones, a “danger zone” where responses were both high risk (3-5) and low comfort (1-3) and a “safe zone” where responses were low risk (1-2) and high comfort (4-5). One-tailed Chi square with Yates correction was performed.

Results: Risk matrix analysis showed a statistical difference among danger zone respondents between junior resident and faculty groups for exposure, pedicle screw placement, neural decompression, inter-body placement, posterolateral fusion and hemostasis (Table 2). Radar graph identifies percent of respondents who fall within the danger zone (Figure 1).

Conclusions: Resident perception of surgical complexity can be evaluated for procedural steps using a risk matrix survey. For PIF, residents assign more risk and are less comfortable performing steps in a training dependent manner. Identification of particular high risk steps, which are uncomfortable, should prompt strict faculty oversight to improve patient safety, monitor resident education and reduce operative time.

Patient Care: Identifying a process for assessing resident comfort and evaluation of risk can be generalized to all procedures; this perception is directly related to patient safety and decreasing OR times.

Learning Objectives: By the conclusion of this session participants should be familiar with a process for obtaining resident self-assessment of procedural steps using a survey.

References: 1. Bridges M and Diamond DL: The financial impact of teaching surgical residents in the operating room. The American Journal Surgery 177: 28-32, 1999. 2. Bakaeen FG, Dhaliwal AS, Chu D, Bozkurt B, Tsai P, LeMarie SA, Wall MJ, Coselli JS, Huh J: Does the level of experience of residents affect outcomes of coronary artery bypass surgery? Annals of Thoracic Surgery 87(4):1127-33, 2009.